A woman's membranes have just ruptured and she states "I feel something in my vagina." The nurse assesses the woman and sees part of the umbilical cord protruding from the vagina. What action by the nurse is best?
A.
Cover the cord with warm sterile saline-soaked compresses.
B.
Push the cord segment back into the vagina.
C.
Position the woman in reverse Trendelenburg.
D.
Take the maternal and fetal vital signs.
ANS: A
Exposure to room air will cause the umbilical cord to dry out, leading to atrophy of the umbilical vessels. The nurse should not attempt to replace the cord but should cover it with a warm, saline-soaked sterile compress. The nurse should also exert upward pressure on the presenting part to relieve cord compression and prevent fetal hypoxia. The woman should be positioned in extreme Trendelenburg, modified Sims, or knee-chest position to take pressure off the cord. Assessing maternal and fetal signs is important, but first the nurse needs to preserve the cord.
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